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Nutritional management for people with diabetes has traditionally focused on blood glucose control. Key studies that evaluated reduction or alteration of dietary protein are summarized in Table 42. At the other end of the spectrum, high-protein diets are a particular concern in patients with diabetes because they increase albuminuria and may accelerate loss of kidney function.
Evidence of biological activity of dietary fats and carbohydrates indicates that an exclusive focus on protein is too limiting with regard to broad effects on health in people with diabetes and CKD. People with diabetes and CKD should receive intervention from a specialty-trained registered dietitian that includes individualized management of multiple nutritional aspects. The Institute of Medicine established guidelines for intake of omega-3 fatty acids, which recognize significant variances in physiologicalpotency between different omega-3 fatty acids. Studies of dietary protein interventions in diabetes and CKD are relatively few, short term, completed in small numbers of participants, and have limited documentation of DKD.
The Renal Dietitians Dietetic Practice Group of the American Dietetic Association recommends nutritional assessment and intervention at the diagnosis of CKD and quarterly thereafter.477Considering that diabetes further complicates CKD care, frequency of assessment may be adjusted based on the needs of individual patients.
Often the hardest parts of living with a chronic health condition are all of the major diet and lifestyle changes that need to be made. Behavioral self-management in diabetes and CKD is particularly challenging because of the intensive nature of the diabetes regimen. The success of strategies to promote glycemic control and minimize progression of CKD depends upon patient self-management, or the ability and willingness of the patient to change and subsequently maintain appropriate behaviors regarding diet, physical activity, medicines, self-monitoring, and medical follow-up visits.
Due to complexity of the behavioral self-management regimen for diabetes and CKD and high frequency of nonadherence, alternative approaches to traditional education should be considered. A recent meta-analysis examining factors that influence adherence to disease management regimens found that patients have the least difficulty with circumscribed regimens (eg, medicines) and the most difficulty with regimens requiring extensive behavior change (eg, dietary change). A recently completed systematic review of 20 studies conducted between 1966 and 2003 measured adherence to diabetes medicines (Table 55).570 The study found that, among patients using oral agents, adherence rates ranged from 36% to 93% and were even lower for insulin. The management plan should include careful coordination of care, addressing both diabetes and CKD. Although intensive glycemic control reduces diabetes complications,116, 134, 562, 564 once patients develop CKD, there may be a tendency to place less emphasis on glucose management. Behavioral adherence should be assessed in all patients, particularly in those who do not respond to therapy. Intensive glycemic control may increase the number of hypoglycemic episodes, with the need to increase food intake to cover peak times of insulin action. Self-management approaches based in behavioral medicine may be effective in enhancing adherence to the management regimen for diabetes and CKD.
No studies were found of interventions to enhance adherence of individuals to management regimens for diabetes and CKD. Assessments and educational efforts should take into consideration modifiable barriers to self-management, should be culturally appropriate, and should consider the unique learning needs of the patient.
Behavior change requires repeated contacts and sustained support from the health care team.
A meta-analysis summarized the numerous clinical trials that have been done to enhance the adherence of people with diabetes to self-management regimens (Table 55).593 These studies generally define adherence as an educational or behavioral issue. Research that pertains to self-management in those with diabetes and CKD is virtually nonexistent. Simplification of the management regimen (including medicines, diet, physical activity, and self-monitoring requirements) may be helpful for encouraging adherence.
Education of the patient regarding medicines should include, at a minimum, the reason the medicine is being prescribed, instruction regarding side effects, importance of adherence, consequences of nonadherence, and signs or symptoms that should trigger a return call or visit to a health care provider.
Aging of the population will require regular reassessment of the patient's ability to independently handle the management regimen.
Development of culturally sensitive educational materials and services is necessary to ensure adherence to medical recommendations and requires time and resources that may be beyond the control of the individual clinician.
The approach to the patient should be individualized, taking into consideration his or her culture, economic situation, knowledge and beliefs regarding the disease and treatment, response to medication (in particular, side effects), ability (emotional, functional, cognitive, visual) to adhere to the prescribed regimen, and changes in status over time. However, dietary protein intake at all stages of CKD appears to have an important impact in this population. Reduction in albuminuria and stabilization of kidney function have been reported with dietary protein intake at the RDA level.
Glomerular hyperfiltration and increased intraglomerular pressure are well-recognized mechanisms of kidney damage induced by excess dietary protein. When protein intake is limited, caloric distribution of the other macronutrients must be addressed. Recommendations for fatty acids usually combine polyunsaturated fatty acids together without differentiating between categories.
The management of diabetes and CKD involves multiple nutrients (macronutrients and micronutrients), including protein, carbohydrate, fat, sodium, potassium, and phosphate, among many others.

Meta-Analysis Demonstrating Reduced Risk of Progression of DKD (Loss of Kidney Function or Increased Albuminuria) by Treatment with Low-Protein Diets. Recommendations for phosphorus and potassium are the same for CKD with and without diabetes. Effect of Reduced Dietary Protein Intake on CKD Stage 5 and Death in Type 1 Diabetes and CKD Stage 2 (inferred) at baseline. In addition, both the qualitative (eg, beef, chicken, or soy sources) and quantitative definition of a low-protein diet differ tremendously among studies.
A registered dietitian who is knowledgeable of both conditions should perform nutritional assessments and interventions. Many people do not learn how much your diet can affect your overall health until they are diagnosed with a chronic illness. Some people have a lot of trouble really knowing how to get started, and also they tend to have a lot of reluctance to start.
Education alone is not sufficient to promote and sustain healthy behavior change, particularly with such a complex regimen. Glucose self-monitoring is particularly important for balancing physical activity and diet against medicines to control glycemia and prevent or impede the progression of complications.116,134,562-564 This regimen requires tremendous effort on the part of the patient. Individual perceptions of dietary restrictions, particularly feelings of deprivation, are difficult for patients and health care professionals to address. Adherence also was found to be related inversely to the number of diabetes medicines prescribed.
While no studies document inattention to glycemic control in early-stage CKD, a recent review of dialysis patient records found diabetes management to be suboptimal.574 Individuals with diabetes and CKD require the attention of a health care team that can address social, educational, emotional, and medical consequences of both conditions.
Although DCCT and UKPDS demonstrated that patients receiving intensive treatment had better glycemic control, they also were more likely to experience weight gain than those receiving usual care. However, 2 meta-analyses have been published that provide valuable information about the most effective approaches for encouraging adherence to the diabetes regimen (Table 55). They perceived physical discomfort, feared hypoglycemia, and had perceptions that they were too overweight. Those that conceptualized adherence as an educational issue tested interventions that involved the development of materials or unique teaching approaches to help people with diabetes learn about the disease and its management. Accordingly, evidence regarding adherence to blood pressure management regimens and to self-management of diabetes were extrapolated to people with diabetes and CKD. Self-management, as described, requires frequent and repeated contacts with health care professionals for education, goal setting, evaluation of progress, and teaching self-monitoring and problem-solving skills. If appropriate, the patient should be instructed that other medicines are available if side effects become unmanageable.
In recent studies of people with prehypertension or untreated stage 1 hypertension, higher protein intake from either soy or predominantly vegetable sources reduced blood pressure in short-term (6 to 12 weeks) feeding studies.200, 201 Along with the DASH trials, these data suggest that predominantly nonmeat protein may have a beneficial effect on blood pressure. Few studies have examined the effects of fatty acid intake or supplements on markers of kidney disease and risk factors in patients with diabetes (Table 41).468-472 Moreover, these studies were short term and performed in small numbers of people, precluding firm conclusions. The dietary protein recommendation should be based on idealized body weight because obesity, which is highly prevalent in the diabetes and CKD population, otherwise would lead to overestimating the dietary protein recommendation.
Phosphorus binders may be needed in patients with advanced CKD because of the emphasis on whole grains and dairy products.
The Work Group is not aware of studies indicating disadvantages from this amount of EPA or DHA.
Substantial differences in amounts and types of fat and carbohydrate also have not been acknowledged adequately. In addition, diets recommended by health care professionals often are viewed as unpalatable and unattractive.
Obtaining accurate dietary histories often is challenging because of the subjective nature of reporting and difficulty with recall.
Thus, the addition of medicines for other common comorbid conditions (eg, hypertension and dyslipidemia) is likely to further reduce adherence. The ADA has developed Standards for Diabetes Self-Management Education.575 These standards summarize evidence that self-management education is most effective when delivered by a multidisciplinary team. Intensive treatment also may mask poor adherence to the treatment regimen, especially adherence to diet and physical activity.
Those that conceptualized adherence as a behavioral issue employed techniques based in behavioral medicine or psychology to foster behavior change (eg, motivational interviewing, verbal persuasion, goal setting, positive reinforcement, social support, and coping, among others).
Establishing and maintaining self-management behaviors likely will require multiple ongoing contacts with members of the health care team. These patients (85% to 89% during the course of the study) also received ACE inhibitors and had similar control of blood pressure and other risk factors irrespective of diet group assignment, indicating that reducing dietary protein provided benefits beyond established medical therapies.181 Benefits of limiting dietary protein intake are more evident in type 1 than type 2 diabetes, but fewer studies have been done in the latter population. Nevertheless, the available evidence suggests that increased intake of omega-3 and monounsaturated fatty acids may be considered because of potentially favorable effects on progression of CKD (Table 41). However, some concerns exist related to the potential for unacceptable levels of mercury or other contaminants.
This type of variability is a potential explanation for the inconsistent results observed between studies evaluating the effect of protein intake on kidney outcomes.
Culinary approaches to enhance appeal of nutrient-appropriate foods should be encouraged, along with methods to make food preparation easy and inexpensive.

For some key nutrients in the regimen recommended for diabetes and CKD, such as sodium and protein (estimated by urinary urea nitrogen excretion), 24-hour urine studies are useful to assess intake and guide counseling.
Maintenance of adherence requires ongoing support from a variety of health care professionals. To our knowledge, no studies have specifically examined adherence of people with diabetes and CKD to self-management regimens. Rates of adherence to an exercise program ranged from 19% to 30% in people with diabetes,571, 572 indicating that compliance issues impact on multiple aspects of disease management. This team should include a combination of expertise in medical treatment, nutrition, teaching skills, and behavioral psychology. Over time, inattention to behavioral aspects of the regimen may mitigate the potential benefits of intensive treatment.
Regardless of how adherence was conceptualized, these studies found that interventions to enhance adherence tend to improve glycemic control.
Pt experiences normal fluidDM, HPN, Glomerulonephritis, Polycystic decreased urine output balance as evidenced by stable Kidney Disease, Obstrution, Infection, Confusion, weakness, 2. To address dietary recommendations for people with diabetes and CKD stages 1 to 4, studies evaluating interventions that reduced or altered sources of dietary protein and other nutrients were reviewed (Table 37 to Table 41).
Based on the available evidence (Table 37 and Table 38), the Work Group concluded that limiting dietary protein will slow the decrease in kidney function and progression of albuminuria, and it may prevent CKD stage 5. Therefore, a DASH-type diet that emphasizes sources of protein other than red meat may be a reasonable alternative to a lower total protein intake in people with hypertension, diabetes, and CKD stages 1 to 2.
Fatty acid intake can be modified easily by substituting canola oil, a blend that includes both omega-3 and monounsaturated fats, for vegetable oils. Nevertheless, in the opinion of the Work Group, these recommendations may be considered for the diabetes and CKD population. An example of a meal plan that meets the nutritional goals of this guideline is provided in Appendix 1. Close monitoring of patients who follow a dietary protein restriction is important to ensure adequate, but not excessive, protein intake.
However, the challenges of modifying behavior to achieve adherence and successful self-management for those with diabetes are well established (Table 55).
Ideal self-management requires vigilance regarding the content of meals and balancing nutritional intake with medicines and physical activity to achieve good glycemic control. Each patient should have an individualized assessment, educational plan, and periodic reassessment pertaining to educational needs. Knowledge was not consistently related to glycemic control, and factors other than knowledge are needed to achieve long-term behavioral change.576 The second conducted a meta-regression analysis on 28 studies between 1990 and 2000 to characterize the components of behavioral interventions most likely to result in improved glycemic control. The greatest improvements were made in interventions involving frequent contact with the patients.
Several brands of salad dressings and butter replacement products made from canola oil are available in most grocery stores. A professional chef designed the menu and accompanying recipes in collaboration with registered dietitians experienced with diabetes and CKD.
Patients should be aware of day-to-day patterns in their blood glucose levels to make informed choices. Table 56 lists the components and principles of a diabetes and CKD self-management program, combining educational elements from the ADA Standards,575 Guideline 5 of the NKF-KDOQI™ CPGs for Hypertension and Antihypertensive Agents in CKD,5 and predictors of nonadherence.
Face-to-face delivery (compared with telecommunication and written materials), cognitive reframing (involving goal setting and problem solving as opposed to didactic education), and interventions that included an exercise component were key to improving glycemic control.577 The principles noted in Table 57 enhance adherence to medical management in other patient populations and, in the opinion of the Work Group, should be applicable to patients with diabetes and CKD. Unfortunately, improvements generally were lost within 1 to 3 months after stopping the intervention.583 No literature was found regarding the frequency and duration of contacts required to make and sustain behavior change in patients with diabetes and CKD.
Regardless of the level of protein intake, 50% to 75% of the protein should be of high biological value, derived predominantly from lean poultry, fish, and soy- and vegetable-based proteins. To reduce intake of saturated fat, consumption of red meats should be reduced, and low-fat or nonfat dairy products should be used. In the view of the Work Group, these types of creative approaches facilitate interest and feasibility for lifestyle modification in diabetes and CKD. However, given that CKD only complicates the self-management regimen, the Work Group concluded that interventions to support and sustain behavior change should be comparable to or exceed those required for good self-management of diabetes. Assess contributing nutritional intake as evidenced nausea, mouth vomiting factors t activity by being free of signs of ulceration, bleeding intolerance.
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Encourage high-calorie,abnormalities toxins disorders dry flaky skin, pruritus, low-protein, low-sodium,(hperkalemia) (pericarditis, (HPN, purpura, thin brittle low-potassium snacks. Promote intake of high effusion, metastatic hair biologic volume protein pericardial calcification, HPN, generalized edema.

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